Choosing Wisely Canada recommendations

Family medicine recommendation 13

Do not initiate opioids long term for chronic pain until there has been a trial of available nonpharmacologic treatments and adequate trials of nonopioid medications.

What shared decision making strategies or tools have you implemented in your practice around this recommendation?

I use the Centre for Effective Practice’s Management of Chronic Non-Cancer Pain resources for providers (https://cep.health/tools), particularly the overview of treatments and the various checklists, and Opioid Manager (https://cep.health/clinical-products/opioid-manager). These evidence-based resources help me to develop and implement pain management plans with patients. Information is structured intuitively and organized clearly into categories such as physical activity, self-management, and psychological, physical, and pharmacologic therapies. The evidence for each is scored.

In my teaching practice, residents and trainees build communication and relational skills—and ultimately, a good bedside manner. The Centre for Effective Practice’s chronic noncancer pain tools and resources include talking points to help clinicians communicate, educate, and engage in shared decision making around pain management. This can be a sensitive and difficult topic to discuss, making effective communication all the more important.

What makes shared decision making around this topic challenging or rewarding?

The opioid crisis, changing evidence, prescriber behaviour, and the culture around opioids make this especially difficult to navigate. In the 1990s the pharmaceutical industry drove a rise in opioid prescribing by physicians who were told it was a safe, evidence-based approach. However, we now have evidence of the substantial harms of opioids.

Historically patients have understood opioids to be on the “menu” of treatment options. A skilled exchange about the harms of and alternatives to opioids takes time. For discussing chronic pain with patients, I use the 4 Ps—prevention, psychology, pharmacology, and physical modalities—to guide the conversation and touch on all aspects of this complex issue.

When you hear hoofbeats, it is usually a horse and not a zebra. Patients (and physicians) sometimes believe their cases are unique. But for most patients with chronic pain, that is not the case. It is best to avoid an opioid if possible and to optimize all nonpharmacologic measures and taper opioids where possible.

The greatest successes are with patients who request help to make a change. These patients are most likely to avoid opioids altogether or taper opioids with physician direction and encouragement. These circumstances can be so rewarding, as patients and their care providers are able to set goals based on functional accomplishments instead of pain scale scores. For example, we can focus on lifestyle goals—what they are able to achieve that is important to them.

Why is shared decision making around this specific Choosing Wisely recommendation or clinical topic essential to you?

This topic is dear to me from a patient safety perspective. It aligns with an initiative I am leading: an Opioid Stewardship Program that is being rolled out in partnership with the Saskatchewan Health Authority.

At this stage, we are conducting a pilot in Regina. We are connecting patients with interdisciplinary teams to offer alternatives to opioids. There is counseling, exercise therapy, and education and resources from pharmacists. We hope to reduce new opioid prescriptions and optimize pain management. This program really takes a preventive “upstream” approach to the opioid crisis.

For patients living with chronic pain, this program offers options that are not usually accessible or affordable. We want to increase access to treatments that are not generally covered by the province, like physiotherapy, exercise therapy, psychology, mindfulness, and culturally sensitive care. Prescribing a pill sometimes seems like the only option, especially when patients have accessibility and cost concerns. We hope these expanded supports will translate into positive results in Saskatchewan and can be adopted nationally.